Primary care physicians’ knowledge of travel vaccine and malaria chemoprophylaxis and associated predictors in Qatar

Background In an era of globalization, travel-related illnesses have become a focus of public ‎health concern, especially in the Arab region where travel health services are insufficient and ‎not well-established. This study was conducted to assess travel vaccine and ‎malaria chemoprophylaxis knowledge and associated predictors among primary care physicians‎ (PCPs) in ‎Qatar. Methods This was a cross-sectional study. A structured questionnaire was used to collect ‎data from all physicians working at all 27 primary healthcare centers from March 1st to May 31st 2020.‎ Knowledge scores were computed and a multivariable linear regression model was built to identify predictors of higher knowledge. Results A total of 364 PCPs participated (response rate of 89.2%). Participants’ mean ‎age was 44.5 (±7.8) with 59.1% being males. Their overall mean knowledge score was 9.54/16 (±3.24). Significant predictors of higher knowledge included: aged 40–49 years ‎(1.072; 95% CI: 0.230, 1.915)‎, had medical degree from non-Arab countries ‏‎(0.748; 95% CI: 0.065, ‎‎1.432)‎‏,‏‎ had training in TM ‏ ‏‎(1.405; 95% CI: 0.407, ‎‎2.403), and provided ≥10 consultations/ month ‎(2.585; 95% CI:1.294, 3.876)‎. Online information was the main reported resource of travel medicine consultation. Conclusions The overall PCPs’ mean percentage knowledge score of travel medicine was 59.6% (±20.3). A high volume of pretravel consultation, prior training, middle age group, and medical degree from non-Arab countries were significant predictors of higher ‎knowledge. Continuing ‎education and training provided by recognised international institutions for all PCPs is highly ‎recommended to narrow the gap in travel medicine knowledge.

eligible. Also, were the eligible PCPs approached in person? Could more details be provided on recruitment? In Canada, most primary care physicians were providing primarily virtual care early in the pandemic. What was the situation in Qatar? The response rate was high. Were incentives or compensation provided?
Response: Thank you for your comment.
• This is correct, all PCPs were eligible. We meant by "eligible" those who were not available at the time of data collection (e.g., in quarantine or on sick leave due to . Please see lines 117 for revised text.
• To clarify, at the time of data collection, there were no virtual consultations but were implemented later.
• PCPs were approached in person in their clinics (Please see line 118).
• There were no incentives or compensation provided (Please see line 123).
• The study achieved a high response rate (89.2%) despite the high demands on PCPs caused by the COVID-19 pandemic which could be explained by their interest in this topic and by communicating clearly and concisely the objectives of the survey and that the data collector will follow up with those who do not respond. Please note that we have clarified this in the manuscript (Please see lines 343-347).
Comment #6: Survey -How was the survey formulated and was there a conceptual model that guided your survey development? Were any of the questions taken from validated surveys? How were the destinations selected -informed by frequent travel destinations of reportable travel-related infections? travel patterns from Qatar? The details should be provided and if possible, a copy of the questionnaire included as a supplemental file. (Note: I see the destinations are described in the discussion -i.e., frequent holiday destinations of travellers from -this should be moved up to the methods where you explain the survey).
Response: Thank you for your insightful comment.
• We formulated our survey based on an extensive literature review and input from travel medicine experts in order to have a comprehensive tool that will fulfill the study objectives. Unfortunately, the autohrs of the articles we found reported on the validation of the instruments that used.
• The destinations were selected based on being frequent travel destinations of travellers from Qatar. We have explained this in the method section (Please see lines 139-140).
• I have included a copy of the questionnaire as a supplemental file.
Comment #7: How were postgraduate experience in tropical medicine or developing countries, postgraduate training in TM defined?
Response: Thank you for your comment.
• Postgraduate experience in tropical medicine or developing countries was defined as any engagement in travel medicine practice after graduation from medical school. It was assessed by asking a close-ended question.
• Postgraduate training in TM was defined as receiving any postgraduate degree (Diploma, Master, PhD) or training (workshop, certified short course) or having a membership or fellowship of TM related professional organization. It was also assessed by asking a close-ended question.
• Please see lines 132-135 in the manuscript.
Comment #8: Outcome measurement -The scores computed could range from 0 to 16. What threshold was used to assess adequate or sufficient knowledge? This seems important to the interpretation of your study findings, especially as you describe overall knowledge as inadequate in your abstract.
Response: Thank you for your comment. We did not use a threshold to assess adequate/inadequate knowledge of TM. We calculated the mean score (9.54 ±3.24 out of 16 ) and we built a multivariable linear regression model to identify predictors of higher knowledge score. Please note that we have removed the description "adequate" from the conclusion section.

Comment #9:
Chronbach's alpha -Could you please provide a reference for your assessment that your value was acceptable?
Response: Thank you for your comment. We have provided a reference for good Chronbach's alpha value [referecne #22].
Response: Thank you for your suggestion. We have changed this in the manuscript.
Comment #11: From Figure 1, it looks like there were ~10 physicians with a score of 0. Did these respondents have 0 correct answers or were these a result of missing data/blanks? The authors do not describe how missing data was dealt with in the analysis.
Response: Thank you for your insightful observation. We double-checked the datasheet and found that 9 physicians scored zero due to either incorrect or "don't know" answers (please see lines 140-142). Missing data were dealt with through list-wise deletion. We have included this in the manuscript under "Statistical analysis" section (line 156).

Comment #12:
There has been a similar study conducted in Qatar and so any references to this paper Response: Thank you for bringing this matter to our attention.
• We were aware of Al-Hajri et al. study. However, we believe that our study is the first that examined the predictors of TM knowledge among PCPs in Qatar, which were not examined by Al-Hajri et al.'s article. In addition, these authors did not calculate the knowledge score; instead, they reported mere frequencies of the correct answers pre-and post-symposium. • We have modified the statement in the intro to "However, little is known about their knowledge of TM" as suggested (Please see line 89-90).
Comment #13: Authors do not discuss the implications of their work. This work replicates findings from both Qatar and other regions and in that respect, is not novel. Given that, the findings should be placed in context with the current state of travel medicine training and provision in Qatar. What should ideally be done differently based on the results of your survey? How can your findings be used to effectively improve TM knowledge among PCPs?
Response: Thank you for your insightful comment. Kindly note that we had discussed the implications of our study findings under the Conclusion section. However, we have modified it to be more specific to our findings (Please see lines 357-366).

Reviewer comments: Reviewer 2
Comment #14: I notify that it is a good article, and it meets the scientific requirements.

I just have minor comments.
• At the level of the section Predictors of travel medicine knowledge, we have the impression that the figure exists before the text, but it is the text that must announce the figure. Is this not a mistake?
• I also suggest documenting evidence of obtaining verbal consent from study participants.
• At the level of discussion, the beginning of the paragraph I suggest replacing "examine" with "evaluate".
Response: Thank you for this positive feedback and suggestion.
• We agree that the text proceeds the figure. As you can see in the following sentence copied from the predictors section "As shown in Table 5, participants who were aged between 40 and 49 years were significantly more likely to score higher in TM knowledge compared to participants who were aged 50 years or more by 1.072 scores (95% CI: 0.230, 1.915)" the text preceeds the figure.
• Kindly note that we have documented evidence of obtaining verbal consent from study participants under the Ethical Considerations subheading (Please see lines 163-164).
• Kindly note that we replaced "examine" with "evaluate" as suggested (Please see line 244).
Journal Requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.
Response: Please note that we have reviewed PLOS ONE's style requirements and edited our manuscript accordingly.

2.
We note that participants provided oral consent. Please also state in the Methods:-Why written consent could not be obtained-Whether the Institutional Review Board (IRB) approved use of oral consent-How oral consent was documented.
Response: Thank you for your observation. We believe it was a misprint. Please note that we have obtained written consent from study participants. We have corrected this in the manuscript.
3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.
Response: Please note that we have described our questionnaire in the Methods section and we included a copy of the study questionnaire as Supporting Information.

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Response: Please note that we have removed funding-related text from our manuscript and we included amended statements within the cover letter as requested.
In addition, please note that in the case Qatar National Library (QNL) cover the article processing charges (APC) of our publication, we will need to add the following statement in the acknowledgment section of the article: "Open Access funding provided by the Qatar National Library". This is a requirement of the library.
Please update the Funding Statement section of the online submission form as follow: • Initials of the authors who received each award: Ayman Al-Dahshan (AAD) • Grant numbers awarded to each author: MRC-01-19-324. • The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Response: Please note that Qatar National Library (QNL) may cover the article processing charges (APC) of our publication. In that case, we will request an unpaid invoice that is addressed to the library.

6.
Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.
Response: Thank you for your comment. Please note that we have double-checked the reference list and made the following changes: • We have updated reference number 7 to be: [7] Angelo K, Kozarsky P, Ryan E, Chen L, Sotir M. What proportion of international travellers acquire a travel-related illness? A review of the literature.
• We have removed reference number 23 because we noted that it is no more accessible (retracted).  vol. 7, no. 2B, pp. 516-20]